Literature DB >> 18544173

The future of patient safety: Surgical trainees accept virtual reality as a new training tool.

Rachel Rosenthal¹, Walter A Gantert, Christian Hamel, Jürg Metzger, Thomas Kocher, Peter Vogelbach, Nicolas Demartines, Dieter Hahnloser.

Abstract

BACKGROUND: The use of virtual reality (VR) has gained increasing interest to acquire laparoscopic skills outside the operating theatre and thus increasing patients' safety. The aim of this study was to evaluate trainees' acceptance of VR for assessment and training during a skills course and at their institution.
METHODS: All 735 surgical trainees of the International Gastrointestinal Surgery Workshop 2006-2008, held in Davos, Switzerland, were given a minimum of 45 minutes for VR training during the course. Participants' opinion on VR was analyzed with a standardized questionnaire.
RESULTS: Fivehundred-twenty-seven participants (72%) from 28 countries attended the VR sessions and answered the questionnaires. The possibility of using VR at the course was estimated as excellent or good in 68%, useful in 21%, reasonable in 9% and unsuitable or useless in 2%. If such VR simulators were available at their institution, most course participants would train at least one hour per week (46%), two or more hours (42%) and only 12% wouldn't use VR. Similarly, 63% of the participants would accept to operate on patients only after VR training and 55% to have VR as part of their assessment.
CONCLUSION: Residents accept and appreciate VR simulation for surgical assessment and training. The majority of the trainees are motivated to regularly spend time for VR training if accessible.

Entities: Disease Species

Year: 2008 PMID： 18544173 PMCID： PMC2483968 DOI： 10.1186/1754-9493-2-16

Source DB: PubMed Journal: Patient Saf Surg ISSN： 1754-9493

Background

Traditionally, surgical skills training has been taking place in the operating theatre based on the Halstedian apprenticeship model [1]. However, economic, ethical, medico-legal and educational considerations as well as time constraints due to reduced working hours have led to the introduction of alternative training models. Concerns of negative effects of duty-hours restriction with regards to training have been described [2-4]. Thus, a re-allocation of available time spent for training of core endoscopic basic and advanced procedures using virtual reality as a cornerstone for training courses has been recommended [5]. Moreover, the introduction of laparoscopic surgery requires additional surgical skills. Various training methods for laparoscopic surgery have been developed employing box trainers with synthetic models, cadaveric animal models or anaesthetized pigs and virtual reality (VR) simulators. VR simulators provide a standardized, reproducible, and controlled environment, enabling practice of a variety of tasks or even full procedures to further progress. Simulators allow skills acquisition in a non-clinical, and therefore less costly and to the patient less hazardous environment. This allows a transfer of part of the learning curve from the operating room to a protected environment and therefore has the potential to improve patient's safety. A survey of general surgery program directors on availability of training facilities in the United States has shown a lack of training facilities as well as a need for standards and validated curricula. Whereas 88% of responders estimate that laparoscopic skills labs improve operating room performance and 75% state that such skills labs help to recruit residents, only 55% actually have such a facility [6]. Formal training courses are another possibility to intensively perform practical exercises under supervision of experts and thus to address the lack of widespread training facilities. Yet, they cannot replace continuous skills training, but VR could. The aim of this study was to evaluate the acceptance of VR as an assessment and training tool at a surgical skills training course and at the hospital of their residentship.

Methods

All 735 surgical trainees of the 23rd, 24th and 25th one-week Davos International Gastrointestinal Surgery Workshops 2006, 2007 and 2008 were involved in the study. The workshop consists of a basic course (BC) and an intermediate course (IC) with mostly separate lectures and a total of 25 hours practical exercises (open and laparoscopic using pelvitrainers). According to their previous experience in laparoscopic surgery (number of performed laparoscopic interventions) participants were assigned to either the BC or the IC. The course participants were given timeslots for a total of 45 minutes for VR training and then had to fill in a standardized questionnaire concerning their opinion on VR. Each study participant signed an informed consent form. Twelve fully VR simulators with various hardware and software were available. An example of a VR simulator is shown in Figure 1. All participants were asked to perform a selection of VR basic tasks of the following software packages: Xitact® (Xitact S.A., 1110 Morges, Switzerland), LapMentor™ basic tasks module (Simbionix USA Corp., Cleveland, OH 44106, U.S.A.), LapSim® basic tasks module (Surgical Science, SE 413 14 Göteborg, Sweden) and the SEP™ tasks (SimSurgery AS, 0855 Oslo, Norway). All these tasks were targeting hand-eye coordination and camera navigation. Examples of VR tasks are shown in Figure 2, 3, 4, and 5. Not all course participants could perform all available tasks due to the following reasons: a great variety of simulators and software were in use with not every software running on every simulator. Moreover, the available time participants spent for VR was limited given the great amount of practical open surgery and pelvitrainer exercises during which no virtual reality training was possible in order not to interfere with the conventional exercises. Participation at VR training was voluntary with time-slots given during lectures and breaks. Whereas the time required to complete a basic task is a few minutes only, this time is considerably longer for a whole procedure. Moreover, participants need to get used to the VR simulator prior to perform a complex procedure. Therefore, we chose not to have participants perform complex VR tasks.

Figure 1

VR simulator example. Hardware: Xitact® (Xitact S.A., 1110 Morges, Switzerland), software: LapSim® basic tasks module (Surgical Science, SE 413 14 Göteborg, Sweden)

Figure 2

angled scope task. Viewing a sphere suspended in three-dimensional space on the center of a target by using a 30° angled scope. After the sphere has been correctly centered on the target a next sphere in a different position is presented until three spheres are viewed. Xitact® (Xitact S.A., 1110 Morges, Switzerland)

Figure 3

grasp-and-clip task. Grasping leaking vessels and clipping them before the complete filling of a tub. LapMentor™ basic tasks module (Simbionix USA Corp., Cleveland, OH 44106, U.S.A.)

Figure 4

intracorporal knotting task. Intracorporal knotting. LapSim® basic tasks module (Surgical Science, SE 413 14 Göteborg, Sweden).

Figure 5

three-dimensional environment task. Two-handed manoever with alignment of an arrow in a 3-dimensional environment SEP™ tasks (SimSurgery AS, 0855 Oslo, Norway).

VR simulator example. Hardware: Xitact® (Xitact S.A., 1110 Morges, Switzerland), software: LapSim® basic tasks module (Surgical Science, SE 413 14 Göteborg, Sweden) angled scope task. Viewing a sphere suspended in three-dimensional space on the center of a target by using a 30° angled scope. After the sphere has been correctly centered on the target a next sphere in a different position is presented until three spheres are viewed. Xitact® (Xitact S.A., 1110 Morges, Switzerland) grasp-and-clip task. Grasping leaking vessels and clipping them before the complete filling of a tub. LapMentor™ basic tasks module (Simbionix USA Corp., Cleveland, OH 44106, U.S.A.) intracorporal knotting task. Intracorporal knotting. LapSim® basic tasks module (Surgical Science, SE 413 14 Göteborg, Sweden). three-dimensional environment task. Two-handed manoever with alignment of an arrow in a 3-dimensional environment SEP™ tasks (SimSurgery AS, 0855 Oslo, Norway). All data were entered into a Microsoft Excel 2003 spreadsheet, and SPSS software, version 10.1, was used for statistical investigation. The statistical significance of differences was tested using the χ2-test for categorical variables. A p-value <0.05 was defined as statistically significant.

Results

A total of 527 participants (72%) attended the VR sessions and answered the questionnaires. Three-hundred and fourty-three participants were male (65%) and 184 participants were female (35%). They represented 28 countries. Eighteen percent of the participants were in their first postgraduate year, 29% in the second, 23% in the third, 14% in the fourth, 8% in the fifth and 8% had more than five years of clinical experience. Fifty-eight percent (n = 306) attended the basic course and 42% (n = 221) the intermediate course. Sixty-three percent (n = 332) of the participants didn't have any previous experience with surgical simulators. Overall, the possibility of using VR at the practical course was estimated as excellent or good in 68%, useful in 21%, reasonable in 9% and unsuitable or useless in 2%. Time given to train on VR (minimum of 45 minutes of total 25 hours practical exercises) was estimated as too short in 56%; increasing from 48% in 2006 to 66% in 2008. If such VR simulators were available at their institution, most course participants would train at least one hour per week (46%), two or more hours (42%) and only 12% wouldn't use VR. Most basic course participants would train 2–5 h hours per week (136/290, 47% basic vs. 56/201, 28% intermediate), whereas intermediate participants would train 1 hour per week (119/290, 41% basic vs. 106/201, 53% intermediate, p < 0.001). Similarly, 63% of the participants would accept to operate on patients only after VR training and 55% to have VR as part of their assessment. Table 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 indicate the results of the questionnaire over the three years and the differences between basic and intermediate course participants. Comparing female with male participants, the only significant difference found was the fact that if available at their institution, female participants would spend more time for VR training (female versus male: no time 5.3%/14.8%; 1 hour/week: 48.2%/44.8%, 2–5 hours/week: 42.4%/37.3%, >5 hours/week: 4.1%/3.1%; p = 0.019). The acceptance of VR performance scores as assessment was significantly higher in first postgraduate year participants than in more experienced participants (72.2% first/50.8% second/54.1% third/47.7% ≥fourth postgraduate year; p = 0.021). The possibility to train using VR was most appreciated by first postgraduate year participants (excellent 40.0% first/33.1% second/20.4% third/15.5% ≥fourth postgraduate year; good 37.5% first/35.4% second/46.9% third/42.6% ≥fourth postgraduate year; useful 15.0% first/, 21.5% second/16.3% third/29.5% ≥fourth postgraduate year; p = 0.009). However, there was no significant difference in the opinion on the amount of time given for VR training, if it should become required before operating on patients and on how much time they would spend for such a training if available at their institution. Due to the great differences in number of participants per country it was not possible to draw any conclusions from comparison between countries, languages and cultural background.

Table 1

Results of the questionnaire of a total of 527 partipants.

The possibility to train using VR was:
	2006	2007	2008

Excellent	33 (18%)	57 (35%)	48 (32%)
Good	76 (41%)	68 (41%)	58 (39%)
Useful	47 (25%)	26 (16%)	39 (20%)
Reasonable	27 (14%)	11 (7%)	9 (6%)
Unsuitable/useless	3 (2%)	1 (1%)	5 (3%)